Percutaneous central venous catheters versus peripheral cannulae for delivery of parenteral nutrition in neonates

A review of neonatal peripherally inserted central venous catheters in extremely or very low birthweight infants based on a 3-year clinical practice: Complication incidences and risk factors

BACKGROUND

The application of peripherally inserted central venous catheters (PICCs) in neonates has proven effective in avoiding repetitive insertions and excessive use of transfusion consumables. However, the frequent occurrence of PICC-associated complications deserves special attention, especially in extremely or very low birthweight (E/VLBW) infants, which in turn affects the quality of neonatal PICC practice. Therefore, we conducted a retrospective study of a 3-year clinical practice of neonatal PICCs in E/VLBW infants to understand the incidences of various catheter-related complications and their risk factors to help form an empirical summary and evidence-based guidance for the improvement of practice.

METHODS

A retrospective study was conducted based on a 3-year practice of neonatal PICCs in E/VLBW infants. Neonatal health records were collected, including demographic characteristics, PICC placement data, and treatment information.

RESULTS

A total of 519 E/VLBW infants were included in this study. There were 77 cases of complications involving 72 infants with an overall incidence of 12.13%. The order of incidences of different complications from high to low was phlebitis (7.71%), malposition (3.66%), leakage (1.35%), pleural effusion (1.15%), central line-associated bloodstream infection (0.58%, 0.25/1,000d), and accidental removal (0.38%). Multivariate analysis revealed that the inserted vessel was an independent risk factor for PICC-associated complications (mainly phlebitis; p = 0.002). Neonatal PICCs inserted in the axillary vein were only one-tenth (p = 0.026) as likely to cause phlebitis as in the basilic vein, whereas when applied in the saphenous vein, neonatal PICCs were five times as likely to cause phlebitis (p = 0.000).

CONCLUSION

E/VLBW infants might be more inclined to develop PICC-associated phlebitis. Catheters inserted in the axillary or basilic vein are preferred if possible.

Umbilical Venous Catheters and Peripherally Inserted Central Catheters: Are They Equally Safe in VLBW Infants? A Non-Randomized Single Center Study

Background and Objective: Peripherally inserted central catheters (PICC) and umbilical venous catheters (UVC) are frequently used for vascular access in neonatal intensive care units (NICUs). While there is a significant need for these devices for critically ill neonates, there are many complications associated with their use. We aimed at investigating the incidence of UVC and PICC complications in very low birth weight (VLBW) infants. Materials and Methods: This is an observational study performed with neonates of the tertiary General Hospital of Piraeus, Greece, during an 18 month-period. Seventy-one neonates were recruited and divided into two groups: 34 neonates with PICC and 37 neonates with UVC. We recorded: Catheter dwell time, the causes of catheter removal, other complications, infections, and catheter tip colonization rates. Results: No significant statistical differences were noticed between the 2 study groups with regards to demographic characteristics, causes for catheter removal, catheter indwelling time or the incidence of nosocomial infection. Eleven UVC tips and no PICC tips were proved colonized (p = 0.001) following catheter removal. Conclusions: The incidence of complications associated with the use of UVCs and PICCs in VLBW infants did not significantly differ in our study. Their use seems to be equally safe. Further studies, with larger samples, are necessary to confirm our results.

Influence of Parenteral Nutrition Delivery Techniques on Growth and Neurodevelopment of Very Low Birth Weight Newborns: A Randomized Trial

Background and Objectives: In very low birth weight (VLBW) newborns, parenteral nutrition (PN) is delivered via a peripheral venous catheter (PVC), a central venous catheter (CVC), or a peripherally inserted central venous catheter (PICC). Up to 45% of PICCs are accompanied by complications, the most common being sepsis. A PVC is an unstable PN delivery technique requiring frequent change. The growth and neurodevelopment of VLBW newborns may be disturbed because of catheters used for early PN delivery and complications thereof. The aim of the conducted study was to evaluate the effect of two PN delivery techniques (PICC and PVC) on anthropometric parameters and neurodevelopment of VLBW newborns. Materials and Methods: A prospective randomized clinical trial was conducted in VLBW (≥750–<1500 g) newborns that met the inclusion criteria and were randomized into two groups: PICC and PVC. We assessed short-term outcomes (i.e., anthropometric parameters from birth until corrected age (CA) 36 weeks) and long-term outcomes (i.e., anthropometric parameters from CA 3 months to 12 months as well as neurodevelopment at CA 12 months according to the Bayley II scale). Results: In total, 108 newborns (57 in the PICC group and 51 in the PVC group) were randomized. Short-term outcomes were assessed in 47 and 38 subjects, and long-term outcomes and neurodevelopment were assessed in 38 and 33 subjects of PICC and PVC groups, respectively. There were no differences observed in anthropometric parameters between the subjects of the two groups in the short- and long-term. Mental development index (MDI) < 85 was observed in 26.3% and 21.2% (p = 0.781), and psychomotor development index (PDI) < 85 was observed in 39.5% and 54.5% (p = 0.239) of PICC and PVC subjects, respectively. Conclusions: In the short- and long-term, no differences were observed in the anthropometric parameters of newborns in both groups. At CA 12 months, there was no difference in neurodevelopment in both groups.

Retrospective Cohort Analysis of Central Line Associated Blood Stream Infection following Introduction of a Central Line Bundle in a Neonatal Intensive Care Unit

Background

Central Line Associated Bloodstream Infections (CLABSI) constitute a leading cause of morbidity and mortality in neonatal populations. There has been an overwhelming increase in the use of evidence-based care practices, also known as bundles, in the reduction of these infections. In this report, rates of CLABSI and central line utilisation were examined following the introduction of a central line bundle in our Neonatal Intensive Care Unit (NICU) at the Canberra Hospital.

Methods

The research undertaken was a retrospective cohort study in which newborn infants admitted to the Canberra Hospital NICU between January 2011 and December 2016 and had a central line inserted were included in the study. Data regarding central line days, bed days, infection rates, and patient demographics were collected before and after the introduction of an intervention bundle. CLABSI rates were calculated per 1,000 central line days for before (2011-2013) and after (2014-2016) the introduction of the bundle. The postintervention period was retrospectively analysed for compliance, with data regarding the completion of maintenance forms and insertion forms collected.

Results

Overall, the results showed a significant decrease in CLABSI rates from 8.8 per 1,000 central line days to 4.9 per 1,000 central line days in the intervention period (p<0.001). Central line utilisation ratio (CLUR: ratio of central line days to bed days) was also reduced between pre- and postintervention periods, from 0.177 (4414/25013) to 0.13 (3633/27384; p<0.001). Compliance to insertion forms and maintenance forms was observed to increase within the intervention period.

Conclusion

The implementation of a central line bundle was effective in reducing both CLABSI rates and dwell time (CLUR) for central venous catheters.

Dwell time and risk of central-line-associated bloodstream infection in neonates

BACKGROUND

Umbilical venous catheters (UVCs) or peripherally inserted central catheters (PICCs), widely used in high-risk neonates, may have a threshold dwell time for subsequent increased risk of central-line-associated bloodstream infection (CLABSI).

AIM

To evaluate the CLABSI risks in neonates having either UVC, PICC, or those having both sequentially.

METHODS

The study included 3985 infants who had UVC or PICC inserted between 2007 and 2009 cared for in 10 regional neonatal intensive care units: 1392 having UVC only (group 1), 1317 PICC only (group 2), and 1276 both UVC and PICC (group 3).

FINDINGS

There were 403 CLABSIs among 6000 venous catheters inserted, totalling 43,302 catheter-days. CLABSI rates were higher in group 3 infants who were of lowest gestation (16.9 per 1000 UVC-days and 12.5 per 1000 PICC-days; median: 28 weeks) when compared with group 1 (3.3 per 1000 UVC-days; 37 weeks) and group 2 (4.8 per 1000 PICC-days; 30 weeks). Life table and Kaplan-Meier hazard analysis showed that UVC CLABSI rate increased stepwise to 42 per 1000 UVC-days by day 10, with the highest rate in group 3 (85 per 1000 UVC-days). PICC CLABSI rates remained relatively stable at 12-20 per 1000 PICC-days. Compared to PICC, UVC had a higher adjusted CLABSI risk controlled for dwell time. Among group 3, replacing UVC electively before day 4 may have a trend of lower CLABSI risk than late replacement.

CONCLUSION

There was no cut-off duration beyond which PICC should be removed electively. Early UVC removal and replacement by PICC before day 4 might be considered.

A Study of Morbidity and Cost of Peripheral Venous Cannulation in Neonates Admitted to Paediatric Surgical Intensive Care Unit

INTRODUCTION

Peripheral venous access in sick neonates is indicated for administration of fluids, drugs or nutrients.

AIM

We conducted an audit of peripheral venous access in neonates admitted to paediatric surgical intensive care unit to study the morbidity, time spent on cannulation and cost with its use.

MATERIALS AND METHODS

One hundred consecutive neonates requiring hospital admission to paediatric surgical intensive care unit in a period of one year were included in the study. Peripheral venous access was secured in all patients. We conducted an audit for the number of venipuncture sites, wastage of cannulae, cost, time spent on cannulation and morbidity with its use. Neonates were divided into three groups depending on their surgical intervention. Namely, Group A (thoracic procedures), Group B (bowel surgery) and Group C (other surgery and non-operative cases).

RESULTS

In Group A, mean venepuncture sites were 10.66, used cannulae were 5.6, wasted cannulae were 4.3, total cost of cannulation was 870 rupees and 93.78 minutes were spent in cannulation per neonate. In Group B, mean venepuncture sites were 7.58, used cannulae were 4.35, wasted cannulae were 2.59, total cost of cannulation was 603 rupees and 59.85 minutes were spent in cannulation per neonate. In Group C mean venepuncture sites were 2.78, used cannulae were 2.9, wasted cannulae were 0.57, total cost of cannulation was 232 rupees and 26.51 minutes were spent in cannulation per neonate. Thrombophlebitis severity was greater in neonates who had longer ICU stay and ventilator dependent days.

CONCLUSION

Peripheral venous cannulation of longer duration is costly, time consuming, and associated with significant neonatal morbidity. It may be worthwhile to consider alternative vascular devices such as peripherally inserted central catheters or central venous catheters in such situations.

Early removal versus expectant management of central venous catheters in neonates with bloodstream infection

BACKGROUND

Uncertainty exists regarding the management of newborn infants with a bloodstream infection and a central venous catheter in place. The central venous catheter may act as a nidus for infecting organisms and observational studies have suggested that early removal of the catheter is associated with a lower incidence of persistent or complicated infection. However, since central venous catheters provide secure vascular access to deliver nutrition and medications, the possible harms of early removal versus expectant management also need to be considered.

OBJECTIVES

To determine the effect of early removal versus expectant management of central venous catheters on morbidity and mortality in newborn infants with bloodstream infections.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 11), MEDLINE (1966 to October 2015), EMBASE (1980 to October 2015), CINAHL (1982 to October 2015), conference proceedings and previous reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials that compared early removal versus expectant management of central venous catheters in neonates with bloodstream infections.

DATA COLLECTION AND ANALYSIS

We used the standard methods of the Cochrane Neonatal Review Group.

MAIN RESULTS

We did not identify any eligible randomised controlled trials.

AUTHORS' CONCLUSIONS

There are no trial data to guide practice regarding early removal versus expectant management of central venous catheters in newborn infants with bloodstream infections. A simple and pragmatic randomised controlled trial is needed to resolve the uncertainty about optimal management in this common and important clinical scenario.

Percutaneous central venous catheters versus peripheral cannulae for delivery of parenteral nutrition in neonates

BACKGROUND

Neonatal parenteral nutrition may be delivered via peripheral cannulas or central venous catheters (umbilical or percutaneous). As the result of complications associated with umbilical catheters, many neonatal units prefer to use percutaneous catheters after initial stabilisation. Although they can be difficult to place, these catheters may be more stable than peripheral cannulae and require less frequent replacement. These delivery methods may be associated with different risks of adverse events, including acquired invasive infection and extravasation injury.

OBJECTIVES

To determine the effects of infusion of parenteral nutrition via percutaneous central venous catheters versus peripheral cannulae on nutrient input, growth and development and complications among hospitalised neonates receiving parenteral nutrition in terms of adverse consequences such as bacteraemia or invasive fungal infection, cardiac tamponade or other extravasation injuries.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (1966 to June 2015) and EMBASE (1980 to June 2015), as well as conference proceedings and previous reviews.

SELECTION CRITERIA

Randomised controlled trials that compared delivery of intravenous fluids (primarily parenteral nutrition) via percutaneous central venous catheters versus peripheral cannulae in hospitalised neonates.

DATA COLLECTION AND ANALYSIS

We extracted data using standard methods of the Cochrane Neonatal Group, with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

We found six trials recruiting a total of 549 infants. One trial showed that use of a percutaneous central venous catheter was associated with a smaller deficit between prescribed and actual nutrient intake during the trial period (mean difference (MD) -7.1%, 95% confidence interval (CI) -11.02 to -3.2). Infants in the percutaneous central venous catheter group needed significantly fewer catheters/cannulae (MD -4.3, 95% CI -5.24, -3.43). Meta-analysis of data from all trials revealed no evidence of an effect on the incidence of invasive infection (typical risk ratio (RR) 0.95, 95% CI 0.72 to 1.25; typical risk difference (RD) -0.01, 95% CI -0.08 to 0.06).

AUTHORS' CONCLUSIONS

Data from one small trial suggest that use of percutaneous central venous catheters to deliver parenteral nutrition increases nutrient input. The significance of this in relation to long-term growth and developmental outcomes is unclear. Three trials suggest that use of percutaneous central venous catheters decreases the number of catheters/cannulae needed to deliver nutrition. No evidence suggests that percutaneous central venous catheter use increases risks of adverse events, particularly invasive infection, although none of the included trials was large enough to rule out an effect on uncommon severe adverse events such as pericardial effusion.

Analysis of the potential risk of central intravenous lines and/or total parenteral nutrition with ventriculoatrial shunts

OBJECT

The distal catheter of a ventriculoatrial (VA) cerebrospinal fluid shunt is potentially exposed to bacterial seeding from a subclavian central line. The risk of blood stream infections (BSIs) from central lines increases with administration of total parenteral nutrition (TPN). The potential risks of shunt malfunction or infection in patients with a VA shunt and a concurrent subclavian central line and/or TPN administration have not been studied.

METHODS

A retrospective review of 49 pediatric patients with placement of a VA shunt was performed. Three outcome measures were studied: shunt malfunction, shunt infection, and bacteremia/fungemia requiring shunt removal. All outcomes were measured by 1 year after shunt insertion. We analyzed the following potential risk factors: age at shunt insertion, prior ventriculoperitoneal (VP) shunt, prior shunt infection, abdominal infection/necrotizing enterocolitis (NEC), concurrent subclavian central line, and administration of TPN. The association between each risk factor and outcome was evaluated using Fisher's exact test to generate the relative risk. Additionally, a logistic regression analysis was performed to evaluate the odds ratio of the outcomes to risk factors considering age as a covariate.

RESULTS

The average age at shunt insertion was 6.3 ± 7.6 years. The most common diagnosis was posthemorrhagic hydrocephalus of prematurity (53.1 %). Fifteen patients (30.1 %) had a shunt malfunction within 1 year, 6 (12.2 %) had a shunt infection, and 3 (6.1 %) required removal of the shunt due to bacteremia/fungemia. The age at shunt insertion was not a statistically significant independent risk factor for any of the three outcomes. Prior shunt infection predicted an increased risk for both future shunt malfunction and infection in both the associative relative risk analysis and the age-dependent logistic regression analysis, although the correlation did not reach statistical significance. The presence of a subclavian central line or TPN administration did not statistically increase the risk over baseline for any of the outcomes in either analysis.

CONCLUSIONS

The relatively small number of patients limits the power of the study. Considering this limitation, the data suggests that the presence of a concurrent subclavian central line or administration of TPN does not increase the risk of shunt malfunction or infection over the baseline of this high-risk cohort.

Elevated lipoprotein(a) in a newborn with thrombosis and a family history of dyslipidemia

This paper reports a rare case of elevated lipoproteinemia(a) that evolved into thrombosis during the neonatal period. During the first days of life, the patient presented with an intracardiac thrombus, pulmonary thromboembolism and a hemorrhagic stroke. Initially, the results of the blood tests performed to screen for thrombophilic diseases were normal for the patient's age. The maternal dyslipidemia and the family's positive history of thromboembolism drew attention to an underlying, inherited, thrombophilic defect. Upon further investigation of the thrombophilia, the increase in lipoprotein(a) levels found in the mother and infant enabled the diagnosis of hyperlipoprotein(a) and the administration of appropriate therapy.

Early removal versus expectant management of central venous catheters in neonates with bloodstream infection

BACKGROUND

Uncertainty exists regarding the management of central venous catheters (CVCs) in neonates with bloodstream infections. Early CVC removal may reduce the risk of persistent or complicated infection and its associated morbidity and mortality. However, since CVCs provide secure vascular access to deliver nutrition and medications, the possible harms of early removal versus expectant management need to be considered.

OBJECTIVES

To determine the effect of early removal versus expectant management of CVCs on morbidity and mortality in neonates with bloodstream infections..

SEARCH STRATEGY

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials ((CENTRAL), The Cochrane Library, 2011, Issue 1), MEDLINE (1966 to January 2011), EMBASE (1980 to January 2011), CINAHL (1982 to January 2011), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials that compared early removal versus expectant management of CVCs in neonates with bloodstream infections.

DATA COLLECTION AND ANALYSIS

We used the standard methods of the Cochrane Neonatal Review Group.

MAIN RESULTS

We did not identify any eligible randomised controlled trials.

AUTHORS' CONCLUSIONS

There are no trial data to guide practice regarding early removal versus expectant management of CVCs in neonates with bloodstream infections. While observational data generally indicate that early removal is associated with a lower incidence of persistent or complicated infection, caution should be exercised in applying these findings to practice because of inherent biases in the study design. A simple and pragmatic randomised controlled trial is needed to resolve the uncertainty about optimal management in this common and important clinical scenario.

Individualized catheter surveillance among neonates: a prospective, 8-year, single-center experience

OBJECTIVE

To monitor trends in central line-associated bloodstream infections and clinical sepsis (CLABICS) among neonates and to determine risk factors for infection, especially dwell time.

DESIGN

Prospective, single-center cohort study conducted from 2001 through 2008.

SETTING

University-affiliated tertiary care center.

METHODS

Individualized surveillance of catheter use and CLABICS episodes was conducted. Data were obtained via regular on-site visits made 3 times a week. Trends over time were estimated by Poisson regression, and risk factor analysis was conducted using a Cox proportional hazards model and logistic regression.

RESULTS

In all, 1,124 neonates were exposed to 2,210 central lines for a total of 12,746 catheter-days and 11,467 catheter-days at risk. The median duration of catheter use was 8 (interquartile range, 5-11) days for peripherally inserted central catheters (PICCs) and 4 (interquartile range, 2-6) days for umbilical catheters; 102 CLABICS episodes were detected. The median time to infection was 7 days. Incidence densities were 8.5 CLABICS episodes per 1,000 catheter-days at risk and 8.0 CLABICS episodes per 1,000 catheter-days. The highest rates were identified among neonates weighing 750 g or lower (14.9 CLABICS episodes per 1,000 catheter days at risk) and for PICCs (13.2 CLABICS episodes per 1,000 catheter days at risk). Catheter dwell time was associated with CLABICS for all umbilical catheters (odds ratio [OR], 1.2 per day of use [95% confidence interval {CI}, 1.1-1.3]; P < .001) and for PICCs for up to 7 days (OR, 1.2 [95% CI, 1.1-1.4]; P = .041), but not thereafter (OR, 1.0 [95% CI, 0.9-1.1]; P = .90).

CONCLUSION

Catheter dwell time is a risk factor for CLABICS during the first 7 days, irrespective of catheter type. After 7 days, PICCs are less likely to become infected.

Efficacy of local instillation of recombinant tissue plasminogen activator for restoring occluded central venous catheters in neonates

OBJECTIVE

To evaluate the efficacy of local instillation of tissue plasminogen activator (tPA) for restoring function to occluded central venous catheters (CVCs) in the neonatal population.

STUDY DESIGN

This was a retrospective review of patients admitted to the neonatal intensive care unit during September 2000 to April 2006 who received instillation of tPA for occluded CVCs.

RESULTS

Among 18 infants who received tPA for occluded CVCs, gestational age at birth was 32.5 weeks, birth weight was 1550 g, and gestational age at tPA administration was 39 weeks, with 4 neonates < or =32 weeks' gestational age at tPA administration; age at tPA use was 39 days (medians reported). Ten of 18 (55%) of CVC occlusions were successfully opened after using tPA. No bleeding complications of tPA were noted, including increased or new-onset intraventricular hemorrhage, overt bleeding, or changes in INR or partial thromboplastin time attributed to tPA use. Three patients (16.5%) had bacteremia within 7 days of tPA administration, and no catheter ruptures occurred.

CONCLUSIONS

Local instillation of tPA was successful in restoring function to occluded CVCs in a significant proportion of neonates, although success rates were lower than that reported in populations of older age. Despite the vulnerability of neonates to the potential complications of tPA, no major complications were detected even among premature infants.

A new technique for transumbilical insertion of central venous silicone catheters in newborn infants

Aim: A new technique allowing placement of umbilical silicone venous catheters (USVC) is described and compared with percutaneous silicone venous catheters (PSVC).

Methods: Data were retrospectively recorded for 198 infants with USVC and 141 infants with PSVC.

Results: Overall rate of complications was low and comparable in both groups: thrombosis 1.2%, catheter-related sepsis 3.5% and mechanical obstruction 5%.

Conclusion: A new device allows safe introduction of silicone catheters into the umbilical vein.

Iatrogenic disorders in modern neonatology: a focus on safety and quality of care

The introduction of new modalities of treatment for the very premature infant and advanced life-support systems have led to a decrease in the neonatal mortality rate, and a consequent increase in the population of the tiniest survivors. Many premature infants that survive their neonatal intensive care unit stay have permanent injury to their vital organs including eyes, lungs, brain, and gastrointestinal tract, causing them to have lifelong disabilities. Whether these injuries are a result of their prematurity, or are caused by the life-support systems and treatments is a subject of much dispute. This article explains the process of iatrogenicity and separates the iatrogenic problems that are preventable from those that are currently unpreventable.

Complications of vascular catheters in the neonatal intensive care unit

Insertion of an intravascular catheter is the most common invasive procedure in the neonatal ICU. With every passing decade, technological innovations in catheter materials and sizes have allowed vascular access in infants who are smaller and sicker for purposes of blood pressure monitoring, blood sampling, and infusion of intravenous fluids and medications. There is, however, growing recognition of potential risks to life and limb associated with the use of intravascular catheters. This article reviews complications of venous and arterial catheters in the neonatal ICU and discusses treatment approaches and methods to prevent such complications, based on current evidence.